Honey bee sting reaction

In this case, the beekeeper's symptoms after the sting are not consistent with a Type 1 IgE-mediated hypersensitivity reaction. Fever, body aches, and joint pains are more consistent with a Type III serum sickness-like reaction. However, the time course does not fit with this diagnosis because the onset would have been days to weeks and not hours. Most of these reactions arise from the tissue deposition of antibody-antigen complexes, which precipitate only after sufficient antibody has been formed.

As an example, serum sickness is usually manifested as urticaria with joint pain, fever, fatigue, and lymphadenopathy typically 7 to 10 days after the sting (1). Patients with serum sickness may demonstrate immunoglobulin E (IgE) and immunoglobulin G (IgG) antivenom antibodies. (2)

It is possible these symptoms were mediated by a delayed non-IgE hypersensitivity. I would not think you can definitively attribute the symptoms of fever and body aches to a URI that occurred a few days later.

The fact that she carries an epipen makes me wonder if she has had classic IgE mediated symptoms in the past. I would obtain a detailed history and, since her occupation places her at high risk for repeat stings, immunotherapy should be discussed as a shared patient-provider decision.

Honey bee stings cause higher rates of recurrent anaphylactic reactions compared with stings of vespids (ie, yellow jackets, hornets, and wasps).(3) Unfortunately, honey bee VIT is less effective in preventing future anaphylactic reactions than vespid VIT (eg, 77 percent versus 91 percent in one study) (4), and the protection provided by honey bee VIT does not last as long as that from vespid VIT (5). For these reasons, the duration of honey bee VIT is often extended beyond five years

A recent study showed a tyrosine-adsorbed honey bee immunotherapy preparation protected 89% of honeybee allergic subjects against reactions with repeat stings. There was a clear inverse correlation between the severity of pre-IT and during IT reactions. The duration of IT at the time of re-sting did not affect the efficacy. The safety was overall good, with 18% local reactions. (6)

1. Reisman RE, Livingston A. Late-onset allergic reactions, including serum sickness, after insect stings. J Allergy Clin Immunol 1989; 84:331.
2. Lichtenstein LM, Golden DB. Postscript to bee stings: delayed 'serum sickness'. Hosp Pract (Off Ed) 1983; 18:36, 40, 40A, passim.
3. Cichocka-Jarosz E, Brzyski P, Tobiasz-Adamczyk B, et al. Development of children's hymenoptera venom allergy quality of life scale (CHVAQoLS). Clin Transl Allergy 2013; 3:25.
4. Jakob T, Rauber MM, Perez-Riverol A, et al. The Honeybee Venom Major Allergen Api m 10 (Icarapin) and Its Role in Diagnostics and Treatment of Hymenoptera Venom Allergy. Curr Allergy Asthma Rep 2020; 20:48.
5. Ruëff F, Placzek M, Przybilla B. Mastocytosis and Hymenoptera venom allergy. Curr Opin Allergy Clin Immunol 2006; 6:284.
6. Severino M, Simioni L, Bonadonna P, Cantone R, Cortellini G, Crescioli S, D'Angelo A, La Rosa L, Macchia D, Martignago I, Massolo A, Reccardini F, Bagnasco D, Passalacqua G. Efficacy and safety of honeybee and wasp tyrosine-adsorbed venom immunotherapy. World Allergy Organ J. 2019 Nov 19;12(12):100086. doi: 10.1016/j.waojou.2019.100086. PMID: 31768218; PMCID: PMC6872772.

Carla M. Davis, MD, FAAAAI